Advances in our understanding of the therapeutic action of psycho-analysis should be based on deeper insight into the psychoanalytic process. By ‘psycho-analytic process’ I mean the significant interactions between patient and analyst which ultimately lead to structural changes in the patient’s personality. (Loewald, 1960, p. 16)

More than 50 years have passed since Loewald’s quotation first appeared yet, despite a growing number of empirical investigations that support the efficacy of long-term analytic treatments (Leichsering et al. , 2013; De Maat et al., 2013), we still do not know about the real mechanisms of change. Psychoanalysis is characterized by a plurality of clinical and theorical approaches that lead to many different theories of therapeutic action. This lack of agreement regarding the central construct of therapeutic action creates serious problems for contemporary clinical practice, training, and research (Blatt, Corvelyn, & Luyten, 2006). The problem is rather that the analytic process, as a construct, is ill defined and that it has a less consensual meaning than is usually assumed (Vaughan , Spitzer, Davies, & Roose, 1997). Nevertheless, views of what an analytic process is can be highly subjective and often rest on general propositions that are interpreted subjectively, or that are shared by subgroups of analysts (Abend, 1990). The analytic process concept has been difficult to define because it has such wide connotations that everything in the realm of theory, technique, or clinical data becomes relevant to the construct (Grinberg et. al., 1967). Rangell (1968) long ago noted that what is considered the core of the analytic process has changed from one historical period to another. For example, conceptualizations of the analytic process now extend beyond a focus on the mind of the patient to include the psychology and experience of the analyst, as well as the interactive dimensions that are inherent in the relationship between the analyst and analysand (Jones, 2000; Westen & Gabbard, 2003). Shifts in definitions and conceptualizations of the analytic process are also reflected in discussions that concern the similarities and differences between psychoanalysis and dynamic psychotherapy.

Despite this plurality and richness of theories on therapeutic change mechanisms in psychoanalysis, empirical researchers often either tried to study the efficacy of treatments or describe the therapeutic process, but they only rarely studied long-term treatments through process-outcome studies by trying to investigate the therapeutic factors (Levi, Ablon, & Kaechele, 2012). The great number of theories and the lack of empirical research contributed, from our point of view, in increasing the gap between psychoanalytic theory and clinical practice. It is also noteworthy that active therapeutic factors of treatments may not be the same as those defined by the theoretical clinical model followed by the clinician (Schedler, 2010) and that what therapists actually do in their everyday clincal practice can significantly differ from what they should do, according to their theoretical model (Ablon & Jones, 1998). This has been confirmed by some empirical studies that enlighten how the ideal prototypes of treatment that is derived from trained psychoanalysts’ descriptions do not correspond with their way to conduct psychoanalytic treatments (Ablon & Jones, 1998). In these research efforts that inspired the present research project, responses by expert psychoanalysts to the PQS (1) were used to develop prototypes of the analytic process. The expert panel of analysts (N = 11) was comprised of highly experienced analysts, many of whom are internationally recognized for their expertise. To construct the ideal psychoanalytic prototype, authors asked each member of the panel of experts to rate a list of 100 items that describe different aspects of the psychotherapy process on a scale from 1 to 9, according to how characteristic each item was of their understanding of an ideally conducted analytic treatment hour. The prototype was then created by using a small-sample statistical method for studying points of view, sometimes called Q-technique or Q-type factor analysis (Stephenson, 1953; McKeown & Thomas, 1988).

Besides the need to understand what psychoanalysts really do in their everyday clinical practice, psychoanalytic empirical research is challenged by the requirement to connect what the analyst does (process) with what changed in patient (outcome). In conducting this work, we think that it is absolutely necessary to approach the evaluation of therapeutic outcome from a psychodynamic point of view that evaluates the structural dimension of patient personality, such as defense mechanisms, level of personality organization, object relation development, and use a psychodynamically oriented nosography (Psychodynamic Diagnostic Manual PDM, 2006 ).

The present study is a meaningful extension of the afore-mentioned previous studies that investigated the psychoanalytic process through the construction of an ideal psychoanalytic process prototype (Ablon & Jones, 1998). These research studies actively and originally contributed to the study of the therapeutic process, but they have some critical issues: 1) the analytic process prototype that has been built is ideal and reflects the theoretical conviction of a small group of expert analysts (11), rather than real, everyday clinical practice; 2) the sample of evaluation that was used to build the prototype is based on an excessively low number of observations (11); 3) although the PQS that was used to create the prototype is a highly reliable instrument, its main intention is to evaluate overt processes, thus excluding the evaluation of covert processes that request a high level of inference by the evaluators but that provides them with unique and important information about the analytic process.

In light of the previous consideration, the principal aims of our study are:

a) To construct empirically derived prototypes of the psychoanalytic process.

b) To evaluate the relationship between these prototypes and patient variables (e.g., personality styles, defense functioning, level of personality organization, and transference patterns), treatment variables (e.g., the number of sessions and treatment length), and therapist variables (e.g., experience and the therapists’ emotional responses).

c) To evaluate the predictive validity of these prototypes and their interactions across therapy in relation to long-term changes in patient personality, defense functioning, and symptoms.

Methodological Preliminary Considerations

An important problem in empirical research within psychotherapy as a whole and in psychoanalysis particularly is represented by the conflict between quantitative and qualitative research methods. As psychoanalysis has been divided by those who assert that psychoanalysis is properly a hermeneutic endeavor and those who see it as a science, a comparable debate in research methodology and qualitative and quantitative methods have often been seen as occupying orthogonal positions.

In recent years a third position, which is known as the mixed model research (MMR) approach, has emerged. The MMR, by combining quantitative and qualitative strategies, represents a paradigm shift from pure positivism or pure constructivism to a pragmatic research approach that advances what have been viewed as disparate, at times antagonistic, dichotomies to establish a complementary position. In the MMR paradigm, qualitative (QUAL) and quantitative (QUAN) research is seen not as dichotomous, but as existing on an “interactive continuum” ( Gelo, Braakmann, & Benetka, 2008), with one method potentially broadening or deepening our understanding of a particular research question (Creswell, 2009; Tashakkori & Teddlie, 2003; Teddlie & Tashakkori, 2009).

Another crucial methodological point is represented by the conflict between efficacy and effectiveness approaches. Efficacy studies are characterized by the use of randomized clinical trial designs (see Bateman & Foangy, 2009, for example), with the use of experimental and control groups in testing specific, frequently manualized psychotherapeutic techniques on subjects who meet specified criteria for diagnoses. In this approach, patients are randomly assigned to treatment modalities; patients not meeting research criteria are excluded. Although efficacy studies may facilitate relatively unambiguous results, they have limited generalizability to a broad patient population and to clinical work as practiced today.They do not seem to be suitable for assessing psychoanalityc treatments that are not manualized or are long-term therapies. They aim to make structural changes in patients whom request long-term assessment, etc. In contrast, in effectiveness research, an example of this kind of research are naturalistic design, in which patients are not randomly assigned; rather, they choose their therapists and are accepted into treatment as a result of the therapists’ idiosyncratic selection methods. There is no control group; rather, the patient’s condition prior to treatment is compared to his or her condition during and/or following treatment. The frequency of sessions and the duration of treatment episodes are functions of the patient’s and therapist’s judgment. There are few exclusion criteria so that a wide range of psychopathological conditions, including multiple disorders, tend to be included for investigation and treatment is administered as needed according to the practitioner’s judgment.

Other authors studied psychoanalytic therapies through single case studies (Kächele, Schacter, & Thomä, 2009; Kächele et al., 2006; Hinshelwood, 2010; Gottdiener & Suh, 2012). These research designs are characterized by the repeated assessment of variables during a long period of time and are truly close to an idiographic perspective that, in contrast to other research designs (i.e., RCT and naturalistic studies), give us the opportunity to deeply describe the singular relationship between therapist and patient.

Another methodological critical point is the perspective of evaluation. The majority of empirical studies in psychotherapy have been made by using the patient as main source of data. Although we recognize the importance of the information that is given by the patient, it is important to state that the clinician can also be an optimal source. Previous research has suggested that clinicians tend to make highly reliable and valid judgments if their observations and inferences are quantified by using psychometrically sophisticated instruments such as those used in our study. Data provided by clinician informants have both advantages and disadvantages. With respect to advantages, clinicians are primarily experienced observers whose observations and inferences reflect years of training and experience. By virtue of their experience, they are also likely to have a normative basis from which to make inferences about psychopathology. Their implicit norms may differ from one another and, hence, reduce reliability, just as patients’ implicit norms influence their responses. Nevertheless, we would expect individuals who have seen dozens of patients and worked as clinicians for a multitude of hours to make finer and more reliable discriminations than lay observers (i.e., particularly when these lay observers are mired in their own depression or psychosis) can be assessed by self-report. Second, to the extent that clinicians directly observe important aspects of patients’ behavior, their observations are likely to add value relative to self-reports (Westen & Weinberger, 2004).

In light of the previous consideration, the methodological principles that will guide our research are: 1) To conduct a naturalistic study characterized by the intensive study of several single cases over time;2) to use clinicians’ perspectives of evaluation; 3) to use both quantitative and qualitative methods of analysis.

Methodology

Sampling Procedure.

To collect data, we will use a practice research network approach that is based on clinician evaluations that proved to be useful in previous works (Colli, Tanzilli, Di Maggio, & Lingiardi, 2013; Betan , Heim, Zittel Conklin, & Westen, 2005; Thompson-Brenner & Westen, 2005a; Thompson-Brenner & Westen, 2005b.). First, we will send an email to each member (except candidates) of the rosters of the two principal psychoanalytic associations in Italy. In this e-mail, we will clarify the objectives of our research, its inclusion criteria, and a request to participate. After we will receive the clinicians’ agreement to participate, we will provide them with the material to conduct the study. We requested that they select a patient who was at least 18 years old; who had no psychotic disorder; and who the therapist had seen for a minimum of 16 sessions and a maximum of 1 year (i.e., with a frequency at least of three sessions per week and with the patient lying on the couch). To minimize the selection biases, we will direct clinicians to consult their calendars to select the last patient they saw during the previous week whom met the study criteria. To minimize rater-dependent biases, each clinician was allowed to describe only one patient. Clinicians will not receive any remuneration. First we will ask clinicians to complete a large battery of measures (see Measures section) in order to describe the patients characteristics, treatment, and psychoanalytic process. Clinicians will then describe the psychoanalytic process every month (PPRS and semi structured interview) and every six months they will furnish a more detailed evaluation about treatment and patient changes.

Measures

Psychodiagnostic Chart (PDC) (Gordon & Bornstein, 2013). The PDC is a quick practitioner rating form that integrates the PDM with the ICD or DSM. The PDC may be used for diagnoses, treatment formulations, progress reports, and outcome assessment, as well as for empirical research on personality, psychopathology, and treatment. The aim of the PDC is to create psycho-diagnoses that are more useful to the practitioner by combining the symptom-focused ICD or DSM with the full range and depth of human mental functioning that is addressed by the PDM.

Psychoanalytic Periodical Rating Scale (PPRS) (Beenen & Stoker, 2001). The PPRS is a systematic clinical judgement scale of the psychoanalytic process. It has been constructed and tested in clinical practice by Beenen and Stoker at the Dutch Psychoanalytic Institute (NPI). The PPRS’ items are subdivided into three chapters: Chapter I, General Aspects of the Treatment, which represents significant form elements, such as the general attitude of the patient, treatment commitment, and quality of the sessions in the rated period. The patient’s basic defense and resistance patterns are also being checked, including his or her general mood states in the analysis. The items in Chapter II, The Psychic Content, refer to the conscious and unconscious material that dominates the treatment period under consideration. Next to “classical’ areas, such as sexuality and aggression, the focus is also on issues such as bodily sensations, the types and vicissitudes of patient’s object relationships, and so on. The psychic content is either actual or was present in the past, and can be conscious or unconscious. Chapter III more or less takes up the issues of Chapter I again, but now the focus is on the (curative) interaction between the analyst and analysand. Transference themes, the analyst’s style of work, and the analysand’s reactions to his attitude, interventions, and interpretations, as well as the analyst’s countertransference feelings and general feeling of (dis)satisfaction with the treatment, are the examples of the content of this chapter. The PPRS can be used to judge one or more sessions (a period of treatment). It uses a four-point scale to determine theitems’ presence/absence, agreement/disagreement, and/or a yes or no response, and the subject of the intervention or interpretation. In this study we will use a modified version in which we will add some new items derived from other contribution such as the grid of interventions proposed by Tuckett et al (Tuckett, 2008).

Therapist Response Questionnaire (TRQ) (Betan, Heim, Zittel Conklin, & Westen, 2005). The Therapist Response Questionnaire, which is filled out by a clinician, is designed to assess countertransference patterns in psychotherapy. It consists of 79 items that measure a wide range of thoughts, feelings, and behaviors expressed by therapists toward their patients (see the online data supplement). The statements are written in everyday language so that clinicians of any theoretical approach can use the tool without bias. The questionnaire comprises eight countertransference dimensions that are derived by factor analysis: overwhelmed/disorganized, helpless/inadequate, positive, special overinvolved, sexualized, disengaged, parental/protective, and criticized/mistreated.

Psychotherapy Relationship Questionnaire (PRQ) (Bradley, Heim, & Westen, 2005). The PRQ is a 90-item clinician report questionnaire that is designed to provide a normed, psychometrically valid instrument for assessing transference patterns in psychotherapy for both clinical and research purposes. The items measure a wide range of thoughts, feelings, motives, conflicts, and behaviors that patient express toward their therapist. The 90 items have been derived by reviewing the clinical, theoretical, and empirical literature on transference, therapeutic/working alliance and related constructs, and by soliciting the advice of several experienced clinicians to review the initial item set for comprehensiveness and clarity. Items are written in everyday language, without jargon, so that the instrument can be used equally well by clinicians of any theoretical orientation.

Clinical Data Form. We constructed an ad hoc questionnaire for clinicians to provide general information about themselves, their patients, and the therapies that they used. Clinicians provided basic demographic and professional data, including discipline (psychiatry or psychology), theoretical approach, employment address, hours of work, number of patients in treatment, and supervision, as well as patients’ age, gender, race, education level, and socio economic status. Clinicians also provided data on the therapies, such as the length of treatment and number of sessions.

Semi-structured interview on the psychoanalytic process. To complete the battery of instruments, we added a list of open-ended questions for clinicians in relation to several aspects of the psychoanalytic process: the therapists’ style of intervention, the changes observed in patients in and out of sessions, manner of functioning, the patients’ most relevant dreams, and open questions to permit clinicians to freely describe what they feel was not captured by each of the measures and that they believe could be relevant to describe the psychoanalytic process. This qualitative investigation will permit us to a) confront quantitative with qualitative evaluations in order to enhance reliability; b) obtain more fine-grained information about therapy, clinicians, and patients; and c) collect data to perform several qualitative analyses.

Statistical Analysis

In this study, we will use several statistical procedures. First, in order to construct the prototypes of the psychoanalytic process, we will perform a q analysis to create different groups of sessions characterized by similar psychoanalytic processes. Then, we will calculate the Z standardized scores of every single item for every cluster and we will rank the order for each group’s items of the PPRS. The prototypes will be correlated with the other process and outcome variables. To analyze the trend of the different variables across time and to form an aggregate of several single cases, we will apply aggregated time-series analysis (time-series panel analysis ). Qualitative data will be used to clarify and specify patient, therapist and process characteristics.

Sponsoring institution: The present project will be supported by the Italian Psychoanalytic Society

Footnote

(1) The Psychotherapy Process Q-set, or PQS (Jones, 2000), is a 100-item rating instrument designed to provide a basic language for the description and classification of treatment processes in a form that is suitable for quantitative analysis. The PQS allows clinical judges to formalize and render explicit what usually remains informal, implicit, and intuitive and helps clinical judges to achieve reliable descriptions of complex treatment processes. It provides a standard format that all clinical judges can use to describe the material under study.